The World Health Organisation intends to integrate traditional medicine into national health systems globally. This is an opportunity for building safe, affordable and effective national health systems, especially for Third World countries rich in both medicinal plant resources and traditional knowledge. It is time for governments to fund research into holistic health models instead of squandering more billions on health genomics which will increase intervention and iatrogenic damages to health. Sam Burcher and Dr. Mae-Wan Ho report.
The World Health Organisation (WHO) unveiled its first Global Strategy for Traditional and Complementary Alternative Medicine (TM and CAM) 2002-2005 in January this year.
Still clouding what could be clear horizons for health practices that go back thousands of years, are questions and concerns over policy, regulation, evidence, biodiversity, and preservation and protection of traditional knowledge.
Dr Yashurio Suzuki, WHOs Executive Director for Health Technology says, "TM & CAM are victim of both uncritical enthusiasts and uniformed sceptics", and "this Strategy is intended to tap into its real potential for peoples health and well-being while minimising the risks of unproven or misused remedies".
Problems may arise from the incorrect use of TM, as in the documented case of a Chinese remedy, meant for treating respiratory problems in the short term, which was misused as a long-term diet-aid in the USA, resulting in several deaths.
These isolated cases pale into insignificance, however, compared with adverse reaction to prescribed conventional drugs and treatments that makes it the third leading cause of death in the United States (Box 1).
Adverse reactions to conventional treatments partly to blame for poor health performance in developed countries
The United States, the richest and most powerful nation on earth, consistently perform poorly when it comes to delivery health care to its citizens, despite the factor that its spending on health is the highest by far. Over-use of high tech treatments, and especially iatrogenic damages, are partly to blame.
Studies carried out between 1993 and 1998 give the following estimates of deaths caused conventional treatments and drugs:
These total 225 000 deaths a year from iatrogenic causes, constituting the third leading cause of death in the US, after deaths from heart disease and cancer, and way ahead of the next leading cause of death, cerebrovascular disease. The largest category by far, is non-error, adverse effects of conventional medications, 106 000.
Source: Starfield B. JAMA 2000, 284, 483.
There are concerns that further commercialisation through unregulated use will make traditional therapies unaffordable to those most in need. In Aids-struck countries, three out of four with the illness use some form of TM.
In South Africa, studies are underway on the plant Sutherlandia microhylla, traditionally used as a tonic. The hope is that it will improve body mass and stimulate energy and appetite for those with HIV/AIDS. It must also be remembered that some 25% of modern medicines are descended from plants first used in traditional medicine.
The WHO Strategy took three years to prepare and aims to assist countries to:
The problem is how to implement these recommendations at national levels.
Research and evaluation of TM by WHO has been active since 2000. TM comprises systems such as Traditional Chinese Medicine, Indian Ayurvedua, Arabic Unani medicine, Homeopathy, Osteopathy, Chiropractic practice, etc which are classified in two categories. Medication therapies use herbal medicine, minerals and/or animal parts, while non-medication therapies use "hands on" therapies such as acupuncture, massage (see Box 2), osteopathy and relaxation techniques, meditation and yoga. In countries where the dominant health care system is based on modern medicine, traditional medicines are referred to as CAM.
So far, countries that have successfully integrated TM into their primary health care systems are China, North and South Korea and Vietnam. In China, 40% of health care delivered is TM (see "Radical Solutions Needed For Antibiotic Resistance").
In Africa up to 80% of all health care is TM and 60% of children in the region with malaria are treated with herbal preparations at home. That is because the ratio of TM practitioners to patients is between 1:200 and 1:400, whereas the availability of a conventional GP is 1:20,000. This highlights the need for reliable and affordable herbal medicines that are locally available.
The Chinese herbal remedy Artesmisa annua is recently found to be efficacious against strains of drug-resistant malaria and could prevent some of the 1.5-2 million deaths occurring annually from this infectious disease (see "Two Takes on Malaria" Science in Society Issue 13/14).
More scientists, doctors and medical journals need to be educated that TM/CAM is valuable rather than rejecting it at every opportunity. European homeopathy is not only enjoying integration into the NHS in UK but also gaining some support within the scientific community (see "Water, Water Everywhere", Science in Society 15)
How will the WHO Global Strategy help traditional practitioners and their clients?
Practitioner Lai Yew Loong of Penang, treating a client for trapped nerve at a tiny fraction of the cost of an operation that may not be effective.
Lai Yew Loong is no ordinary traditional practitioner. The sign outside his dingy surgery, - the front room of a small traditional house says, "Chinese Traditional Massage and bone setting". That belies the eclectic combination of traditions that this handsome young Malay-Chinese is using to help his clients. His clientele range across the social strata and ethnic groups, and he charges 25 RM (less than UK £5) for a 20 min session. (Though both the length of the session and the fee appear to be negotiable, as his goal is to help people rather than make money.) He has a full list, and there is only one thing that upsets him more than people not turning up for their appointment, which is people turning up without one. "I need a life too," he said, "I need to see my friends and enjoy my leisure."
Lai has gone through the regular school system, speaks English, as well as Malay and Cantonese Chinese. But his passion in school was Kung Fu. He had 4 Kung Fu teachers in different styles, including karate, tychee and preying mantis. And he deftly demonstrated several movements. He also learned from a herbalist before joining up with the teacher who created the bone-alignment method that he now uses.
"This particular method is only 34 years old." Lai told me, "There are less than 20 people in the whole world that knows how to do it, but eight of them are not practising."
His teacher had 4 masters: two were traditional Chinese practitioners, one was an orthopaedic doctor and the fourth, a Thai practitioner.
"He eliminated all the unscientific elements and created his own school," Lai said. And true to the spirit of his teacher, he keeps textbooks on anatomy in his filing cabinet, with diagrams depicting muscles and tendons over the bones.
Mr. Mohammed Idris and his office at the Consumer Association of Penang are all converts and enthusiastic supporters, after Lai had successfully treated several of them, each for a different ailment. Idris wanted to start a school for Lai, so he can teach his skills to others.
When I first visited Lai, he was treating an Asian woman who could not walk because her foot hurt so much. The doctor at the hospital told her she had trapped nerve, a condition that can only be cured, if at all, by a complicated operation costing thousands of ringgets. She was devastated until someone told her about Lai. After a single visit, she could walk again, and this was her second visit.
I watched him manipulate all the joints in the womans feet, then her ankles, before going on to the knee and the hip joints. "Joints get out of alignment, and thats where the major problem often lies," he declared, "All this talk about trapped nerve is nonsense!"
"I used to walk in the park, and I would see many people jogging and using their body in the wrong way that would lead to problems later on. I really wanted to go up to them and say, Excuse me, sister, you shouldnt walk like that! Come back with me, and Ill show you how. But can you imagine what they would think? Theyd think I am just chatting them up." He smiled so winsomely that I could not imagine why anyone would think that at all.
He invited me to come back for a demonstration treatment. "Otherwise you wont really understand it," he said. How could I refuse? So indeed I went back for the full treatment and seminar. I discovered I had pains in my leg and buttock I never knew were there. I was walking improperly, with my stomach and chest sticking out slightly too far out in front, and thus straining my body. When he eventually finished, and I was told to get up and walk around. What magic. I felt I was walking on air.
"Dont lift heavy weight, wear flat shoes, sit squarely, and dont cross your legs," Lai called after me. Thats the third thing he doesnt like, clients who dont obey orders.
(Dr. Mae-Wan Ho reports from a recent visit in Penang.)
TM/CAM has many ardent providers and supporters in developed countries (see Box). What is not generally recognised is that TM/CAM can be used, and is being used in conjunction with conventional medicine. In many cases, there are no contra-indications that the two disciplines can work together to improve the all-round health of individuals.
CAM is widely used in developed countries: 70% of the population in Canada, 48% in Australia, 42% in USA, and 38% in France. Spending on TM and CAM world-wide is significant and growing rapidly. In Malaysia, the cost of traditional medicine is a tiny fraction of that of western medicine, yet US$500million is spent on TM compared to US$300million on western medicine. In USA, CAM expenditure has reached $2.7 billion per year and in Australia and Canada $80million and $2.4 billion respectively. The global market for TM stands at US$60 billion, with UKs expenditure at US$2.3 billion per year.
WHOs recommendations for TM include protecting and preserving the raw materials that make up the medicines and recording data. Indigenous knowledge is taken seriously and representatives from indigenous tribes are speaking up for their rights. Their goal is to protect biodiversity, but also to stop flagrant biopiracy, when native plants and animals are removed and patented by foreigners, or worse destroyed. Cases abound where indigenous knowledge is forced out after centuries of healthy practice, and replaced by "modern medicine", which are often culturally unsuitable for peoples needs. (See "Hold onto Midwife, here comes the Doctor" Isis News issue 11/12 Oct 2001) This loss of knowledge in turn adversely affects the health of communities.
Some forms of TM/CAM have gained acceptance and approval across the board. In 2001, the UK House of Lords sanctioned the regulation of acupuncture and herbal medicine. Acupuncture originated in China, but is used in 78 countries and practised by both acupuncturists and GPs. There are some 50,000 acupuncturists in Asia and 15,000 in Europe. In the course of three thousand years, the practice has gained a reputation for pain management, pre and post-natal disorders and as part of an alternative cancer cure. With an extensive evidence base and support from the House of Lords, acupuncture is a good candidate for integrating into hospital and primary health care settings. The British Acupuncture Council has also published a series of 44 pamphlets for Family Doctor Publications (in association with the BMA) entitled "Understanding.." Arthritis, Cancer, Stroke, Blood Pressure etc. These pamphlets serve to inform patients as much as GPs.
One in ten Primary Care Trusts (PCT) currently want to establish integrated CAM health services in the UK. Integration is taking place in Healthy Living Centres often partnering PCTs and taking referrals from local GPs. Help in developing information on evaluation, quality control and evidence base is supplied by Prince Charles Foundation for Integrated Health (Box 3). This service is known as "collaborative learning" and provides expert advisors who network results of successful models.
Collaborations are needed at the national level if the Global strategy is to be implemented and currently there are 19 institutions contributing to information sharing and data collection. Many global associations and non-government organisations are springing up that monitor, evaluate and represent aspects of holistic health care professionals and their methods. These set international standards, guidelines and provide links for research, education, development, conservation and the legal status of TM/CAM
To date, only on 25 of WHOs 191 Member States have developed a National TM/CAM policy.
Prince Charles Champions CAM
The Prince of Wales published an article in The Times in 2000 advocating the integration of CAM into NHS. He offered the services of his own Foundation for Integrated Medicine to implement a national strategy for research into the clinical effects of alternative treatments. He donates £500,000 annually to the Foundation. The Prince first turned to CAM when his persistent back problems failed to be treated by conventional medicine. He found that osteopathy relieved his symptoms and also tried herbal medicine and aromatherapy. "The popularity of CAM suggests that people are either dissatisfied with conventional medicine or find genuine relief in such therapies," he said.
If more research validated the advantages of CAM, said the Prince, then these treatments should not be limited to those who could afford to pay for them. Instead they should be made more widely available on the NHS.
Professor Patrick Bateson (Provost of Cambridge and GM animal supporter) is highly critical: "I think he is completely wrong. Prince Charles asserts things in the face of a complete lack of evidence." He continued, "If he is prepared to put his hand in his pocket and finance clinical trials then I would say hurrah."
A spokesperson for the Department of Health, however, said they welcomed Prince Charles views adding there was a role for CAM medicine within the NHS.
A survey sponsored by Foundation for Integrated Medicine investigated CAM in hospital and primary health settings. Hospital records clearly state that integration of CAM therapies such as massage, reflexology, aromatherapy, relaxation and art therapy greatly enhance care for cancer patients. Several pilot studies were undertaken which indicated that CAM significantly decreased the use of drugs amongst radiotherapy patients.
Glastonbury Health Centre set up a model of a fully integrated NHS primary care service between 1994 and 1997 that could be replicated by other NHS practices. Patients were offered courses of acupuncture, herbal medicine, homeopathy, massage therapy and osteopathy. Studies showed that CAM improves general vitality, social functioning, mental health and provide potent pain relief for those with muscular/skeletal problems or physical discomfort. When patients took advantage of both conventional and CAM routes they were able to reduce their usage of other health services such as GP time, prescriptions, X-rays and other tests.
In the UK, CAM practitioners currently outnumber GPs by 40,000 to 36,000. It is potentially an important health resource that is still largely untapped.
Article first published 01/08/02
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